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General NPI Number Information
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NPI Number | 1245628874
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Entity Type | Organization
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Legal Business Name | DYNAMIC BEHAVIOR SOLUTIONS, LLC
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Dates
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Enumeration Date | 01/05/2015
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Last Update Date | 01/20/2015
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Provider Practice Location Address
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Address Line | 2325 RIDGEWOOD DR
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City | MADISONVILLE
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State | KY
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Zip | 42431-9411
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Country | US
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Telephone | 270-339-0127
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1591
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City | MADISONVILLE
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State | KY
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Zip | 42431-0033
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Country | US
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Telephone | 270-339-0127
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Fax |
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Authorized Official
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Title or Position | BOARD CERTIFIED BEHAVIOR ANALYST
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Name | JODI BAUER
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Credential | M.A.
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Telephone | 270-339-0127
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 0108
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | 0048
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License Number State | KY
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